Composition for reducing new-onset diabetes

ABSTRACT

A medical composition for reducing the rate of new-onset diabetes caused by administration of a statin or for inhibiting an increase in blood glucose level by administration of a statin, the composition containing at least one ingredient selected from the group consisting of icosapentaenoic acid and pharmaceutically acceptable salts or esters thereof as an inactive ingredient.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a Continuation of U.S. application Ser. No.16/539,330 filed Aug. 13, 2019, which is a Continuation of applicationSer. No. 15/365,247, filed Nov. 30, 2016 (abandoned), which is aContinuation of application Ser. No. 14/432,012 (now U.S. Pat. No.9,539,230 B2) filed on Mar. 27, 2015, which was filed as PCTInternational Application No. PCT/JP2013/075287 on Sep. 19, 2013, whichclaims the benefit under 35 U.S.C. § 119(a) to Patent Application No.2012-217553, filed in Japan on Sep. 28, 2012, all of which are herebyexpressly incorporated by reference into the present application.

TECHNICAL FIELD

This invention relates to a pharmaceutical composition for reducing newincidence rate of diabetes by statin administration.

BACKGROUND ART

Dyslipidemia is a large risk factor of arteriosclerosis, andarteriosclerosis is the cause of coronary artery diseases such as anginapectoris and myocardial infarction and cerebral stroke such as cerebralhemorrhage and cerebral infarction which are major death causes ofJapanese. In the meanwhile, it has been demonstrated that thesecardiovascular diseases can be prevented and treated by treating suchdyslipidemia.

According to the diagnostic criteria of Atherosclerotic DiseasesPrevention Guideline (2012), dyslipidemia is divided into hyper-LDLcholesterolemia (LDL cholesterol (hereinafter also referred to as“LDL-C”) ≥140 mg/dL), borderline hyper-LDL-cholesterolemia (LDL-C, 120to 139 mg/dL), low HDL cholesterolemia (HDL cholesterol (hereinafteralso referred to as “HDL-C”) <40 mg/dL), and hypertriglyceridemia(triglyceride (hereinafter also referred to as “TG”) ≥150 mg/dL).Recently, the hyper-LDL cholesterolemia, the low HDL-cholesterolemia,and the hypertriglyceridemia are conceived as independent risk factors.

The therapeutic agent used for the dyslipidemia differs by the type ofthe dyslipidemia, and statin is the first choice for treating thehyper-LDL-cholesterolemia. Statin acts in mevalonic acid syntheticpathway wherein biosynthesis of isopentenyl diphosphoric acid anddimethyl allyl diphosphoric acid (starting materials of steroidsynthesis) from acetyl CoA takes place by inhibiting HMG-CoA reductase(EC 1.1.1.34) (hereinafter also referred to as “HMG-CoA”) which is anenzyme catalyzing the reaction of reducing hydroxymethyl glutaryl CoA tomevalonic acid, and thereby suppressing the biosynthesis of thecholesterol. The thus reduced cholesterol biosynthesis also inviteseffects such as enhanced expression of liver LDL (low densitylipoprotein) receptor, increased incorporation of LDL-C from the bloodinto the liver, suppressed VLDL (very low density lipoprotein) secretioninto the blood, and reduced serum TG and increased HDL-C. In view ofsuch function of the statin, statin is also referred to as HMG-CoAreductase inhibitor (HMG-CoA RI).

Statin is effective for the treatment of cardiovascular diseases andprevention of cardiovascular events, and statin has been considered tobe a safe drug with high tolerability. However, recent reports indicaterelation between the statin and the risk of diabetes incidence. Forexample, Non-Patent Document 1 discloses that, in the general evaluationconducted by collecting the results of 16 clinical trials whereinparticipants were divided into the group administered with statin (lipidlowering drug) and the group not administered with the statin, the riskof diabetes incidence was 9% higher in the group administered with thestatin. In addition, United States Food and Drug Administrationannounced a safety communication on the increase of blood glucose andrisk of type 2 diabetes incidence by the statin administration inFebruary, 2012, and the package insert of the statin preparation nowincludes the description that the statin administration invited anincrease of hemoglobin A1c (hereinafter also referred to as “HbA1c”) andfasting blood glucose and significant increase in the diabetes incidence(Non-Patent Document 2). However, it has been conceived, even if therisk of diabetes incidence should increase by the statin administration,the benefit of the reduced risk of the cardiovascular event incidence bythe statin exceeds such risk and there is no reason for stopping thestatin administration. On the other hand, it has also been conceivedthat the statin should be used with the monitoring of the blood glucoseand the glycohemoglobin blood glucose in the case of patients withborderline blood glucose and the like suffering from high risk ofdiabetes incidence (Non-Patent Document 3).

Some reports examine relation between the type of statin and the risk ofthe diabetes incidence. For example, Non-Patent Document 4 evaluated newincidence of the diabetes in aged people of at least 66 years oldadministered with statin, and reports that the risk of the incidence ofthe diabetes significantly increased in the case of atorvastatin,rosuvastatin, and simvastatin compared to the case of pravastatin, andno significant difference was found in the case of fluvastatin andlovastatin. Non-Patent Document 5 describes that, in the meta-analysisof the tolerability and safety of the statin, the risk of the incidenceof the diabetes increased by the statin administration while nodifference was found by the type of the statin.

CITATION LIST Non-Patent Literature

-   [Non-Patent Literature 1] Naveed Sattar et al. (2010) Statins and    risk of incident diabetes: a collaborative meta-analysis of    randomized statin trials. Lancet 375(9716): 735-742.-   [Non-Patent Literature 2] FULL PRESCRIBING INFORMATION of CRESTOR,    AstraZeneca, Revised 28th February, 2012.-   [Non-Patent Literature 3] Allison B. Goldfine (2012) Statins: Is it    really time to reassess benefits and risks? New Engl. J. Med. 366:    1752-1755.-   [Non-Patent Literature 4] Aleesa A. Carter (2013) Risk of incident    diabetes among patients treated with statins: population based study    BMJ 346: f2610.-   [Non-Patent Literature 5] Huseyin Naci (2013) Comparative    Tolerability and Harms of Individual Statins: A Study-Level Network    Meta-Analysis of 246955

Participants From From 135 Randomized Controlled Trials. Circ.Cardiovasc. Qual. and Outcomes Jul. 9, 2013.

SUMMARY OF INVENTION Technical Problem

Usefulness of the statin in treating the cardiovascular diseases andpreventing the cardiovascular events is well recognized, and it has beendifficult to stop the lipid control by the statin even if use of thestatin involved an increase in the risk of diabetes incidence.Accordingly, there is a demand for suppressing increase of the bloodglucose and new diabetes incidence in the patients administered with thestatin, and in particular, in the patients with high risk of diabetesincidence such as patients having a border range blood glucose whilecontinuing the dyslipidemia treatment by statin administration. Themechanism of the increase of the new diabetes incidence risk by statin,however, is yet unclear, and there has been so far no drug capable ofreducing the new diabetes incidence risk in the patients administeredwith the statin. Accordingly, an object of the present invention is toprovide a pharmaceutical composition for suppressing new incidence ofdiabetes of the patient administered with the statin. In the presentinvention, the term “diabetes” is used for type II diabetes unlessotherwise noted.

Solution to Problems

The inventors of the present invention analyzed the trial data obtainedin a large scale randomized controlled trial (Japan EPA InterventionStudy (JELIS)) examining the effects of suppressing onset of thecoronary artery events (primary prevention and secondary prevention) inJapanese hyperlipidemia patients administered with statin by long termadministration of high purity EPA preparation, and for the first timefound that the patients administered with the high purity EPApreparation exhibit no significant increase of the new incidence rate ofthe diabetes; and hence, that the new incidence rate of the diabetes isreduced in the patients administered with the statin by theadministration of at least one member selected from the group consistingof icosapentaenoic acid and pharmaceutically acceptable salts and estersthereof (hereinafter also referred to as “EPA”, and unless otherwisenoted, this also applies to the following), and in particular ethylicosapentate (hereinafter also referred to as “EPA-E”). The inventors ofthe present invention also found by an in vitro test using cultivatedskeletal muscle cells that, while statin decreases glucose uptake by theskeletal muscle cells, the EPA suppresses such glucose uptake decreaseby the skeletal muscle cell by statin, and hence, that the EPA iscapable of suppressing the blood glucose increase by statin.

Accordingly, the present invention provides the pharmaceuticalcomposition as described below.

(1) A pharmaceutical composition for reducing new incidence rate ofdiabetes due to administration of statin (HMG-CoA RI) containing atleast one member selected from the group consisting of icosapentaenoicacid and its pharmaceutically acceptable salts and esters as itseffective component.

(2) A pharmaceutical composition according to the above (1) which isadministered to a patient having a serum HDL cholesterol concentrationof less than 40 mg/dL.

(3) A pharmaceutical composition according to the above (1) which isadministered to a low HDL cholesterolemia patient.

(4) A pharmaceutical composition according to the above (2) or (3) whichis administered to a patient having a serum triglyceride concentrationof at least 150 mg/dL.

(5) A pharmaceutical composition according to the above (2) or (3) whichis administered to a hypertriglyceridemia patient.

(6) A pharmaceutical composition according to any one of the above (1)to (5) which is administered to a patient administered with HMG-CoA RIhaving a fasting blood glucose of less than 126 mg/dL.

(7) A pharmaceutical composition according to any one of the above (1)to (6) which is administered to a patient administered with HMG-CoA RIhaving a fasting blood glucose of at least 110 mg/dL and less than 126mg/dL.

(8) A pharmaceutical composition according to any one of the above (1)to (6) which is administered to a patient administered with HMG-CoA RIhaving a fasting blood glucose of at least 100 mg/dL and less than 110mg/dL.

(9) A pharmaceutical composition according to any one of the above (1)to (8) which is administered to a patient administered with HMG-CoA RIhaving impaired glucose tolerance or obesity.

(10) A pharmaceutical composition according to any one of the above (1)to (9) wherein at least one member selected from the group consisting oficosapentaenoic acid and its pharmaceutically acceptable salts andesters is ethyl icosapentate or icosapentaenoic acid (free acid).

(11) A pharmaceutical composition for suppressing increase of the bloodglucose due to administration of statin (HMG-CoA RI) containing at leastone member selected from the group consisting of icosapentaenoic acidand its pharmaceutically acceptable salts and esters as its effectivecomponent.

(12) A pharmaceutical composition according to the above (11) which isadministered to a patient having a serum HDL cholesterol concentrationof less than 40 mg/dL.

(13) A pharmaceutical composition according to the above (11) which isadministered to a low HDL cholesterolemia patient.

(14) A pharmaceutical composition according to the above (12) or (13)which is administered to a patient having a serum triglycerideconcentration of at least 150 mg/dL.

(15) A pharmaceutical composition according to the above (12) or (13)which is administered to a hypertriglyceridemia patient.

(16) A pharmaceutical composition according to any one of the above (11)to (15) which is administered to a patient administered with HMG-CoA RIhaving a fasting blood glucose of less than 126 mg/dL.

(17) A pharmaceutical composition according to any one of the above (11)to (16) which is administered to a patient administered with HMG-CoA RIhaving a fasting blood glucose of at least 110 mg/dL and less than 126mg/dL.

(18) A pharmaceutical composition according to any one of the above (11)to (16) which is administered to a patient administered with HMG-CoA RIhaving a fasting blood glucose of at least 100 mg/dL and less than 110mg/dL.

(19) A pharmaceutical composition according to any one of the above (11)to (18) which is administered to a patient administered with HMG-CoA RIhaving impaired glucose tolerance or obesity.

(20) A pharmaceutical composition according to any one of the above (11)to (19) wherein at least one member selected from the group consistingof icosapentaenoic acid and its pharmaceutically acceptable salts andesters is ethyl icosapentate or icosapentaenoic acid (free acid).

(21) A pharmaceutical composition according to any one of the above (1)to (20) wherein EPA content ratio in total fatty acid and itsderivatives is at least 96.5% by weight.

(22) A pharmaceutical composition according to any one of the above (1)to (21) wherein the EPA is orally administered at a dose of 0.9 g/day to2.7 g/day.

(23) A pharmaceutical composition according to any one of the above (1)to (22) wherein the EPA is administered at least for 2 years.

(24) A pharmaceutical composition according to any one of the above (1)to (23) wherein the composition is used in combination with HMG-CoA RI.

(25) A pharmaceutical composition according to any one of the above (1)to (24) wherein the composition contains the EPA and the HMG-CoA RI.

(26) A pharmaceutical composition according to any one of the above (1)to (25) wherein the composition is used in combination with a diettherapy.

(27) A pharmaceutical composition according to any one of the above (1)to (26) wherein the composition is capable of, in a patient administeredwith statin (HMG-CoA RI), reducing the incidence rate of thecardiovascular event, and in particular, incidence rate of thecardiovascular event that could not be prevented by the singleadministration of the HMG-CoA RI, or serum T-Cho concentration and/orserum TG concentration.

The present invention also provides the method as described below.

(28) A method for reducing new incidence rate of diabetes due toadministration of HMG-CoA RI comprising the step of administering apharmaceutical composition containing at least one member selected fromthe group consisting of icosapentaenoic acid and its pharmaceuticallyacceptable salts and esters as its effective component to a patientadministered with statin (HMG-CoA RI).

(29) A method according to the above (28) wherein the patient has aserum HDL cholesterol concentration of less than 40 mg/dL.

(30) A method according to the above (28) wherein the patientsimultaneously suffers from low HDL cholesterolemia.

(31) A method according to the above (29) or (30) wherein the patienthas a serum triglyceride concentration of at least 150 mg/dL.

(32) A method according to the above (29) or (30) wherein the patientsimultaneously suffers from hypertriglyceridemia.

(33) A method according to any one of the above (28) to (32) wherein thepatient has a fasting blood glucose of less than 126 mg/dL.

(34) A method according to any one of the above (28) to (33) wherein thepatient has a fasting blood glucose of at least 110 mg/dL and less than126 mg/dL.

(35) A method according to any one of the above (28) to (33) wherein thepatient has a fasting blood glucose of at least 100 mg/dL and less than110 mg/dL.

(36) A method according to any one of the above (28) to (35) wherein thepatient has impaired glucose tolerance or obesity.

(37) A method according to any one of the above (28) to (36) wherein atleast one member selected from the group consisting of icosapentaenoicacid and its pharmaceutically acceptable salts and esters is ethylicosapentate or icosapentaenoic acid (free acid).

(38) A method for suppressing increase of blood glucose due toadministration of HMG-CoA RI comprising the step of administering apharmaceutical composition containing at least one member selected fromthe group consisting of icosapentaenoic acid and its pharmaceuticallyacceptable salts and esters as its effective component to a patientadministered with statin (HMG-CoA RI).

(39) A method according to the above (38) wherein the patient has aserum HDL cholesterol concentration of less than 40 mg/dL.

(40) A method according to the above (38) wherein the patientsimultaneously suffers from low HDL cholesterolemia.

(41) A method according to the above (39) or (40) wherein the patienthas a serum triglyceride concentration of at least 150 mg/dL.

(42) A method according to the above (39) or (40) wherein the patientsimultaneously suffers from hypertriglyceridemia.

(43) A method according to any one of the above (38) to (42) wherein thepatient has a fasting blood glucose of less than 126 mg/dL.

(44) A method according to any one of the above (38) to (43) wherein thepatient has a fasting blood glucose of at least 110 mg/dL and less than126 mg/dL.

(45) A method according to any one of the above (38) to (43) wherein thepatient has a fasting blood glucose of at least 100 mg/dL and less than110 mg/dL.

(46) A method according to any one of the above (38) to (45) wherein thepatient has impaired glucose tolerance or obesity.

(47) A method according to any one of the above (38) to (46) wherein atleast one member selected from the group consisting of icosapentaenoicacid and its pharmaceutically acceptable salts and esters is ethylicosapentate or icosapentaenoic acid (free acid).

(48) A method for improving abnormal glucose tolerance or obesity of apatient administered with HMG-CoA RI having abnormal glucose toleranceor obesity comprising the step of administering a pharmaceuticalcomposition containing at least one member selected from the groupconsisting of icosapentaenoic acid and its pharmaceutically acceptablesalts and esters as its effective component to a patient administeredwith statin (HMG-CoA RI) having abnormal glucose tolerance or obesity.

(49) A method according to the above (48) wherein the patient has aserum HDL cholesterol concentration of less than 40 mg/dL.

(50) A method according to the above (48) wherein the patientsimultaneously suffers from low HDL cholesterolemia.

(51) A method according to the above (49) or (50) wherein the patienthas a serum triglyceride concentration of at least 150 mg/dL.

(52) A method according to the above (49) or (50) wherein the patientsimultaneously suffers from hypertriglyceridemia.

(53) A method according to any one of the above (48) to (52) wherein thepatient has a fasting blood glucose of less than 126 mg/dL.

(54) A method according to any one of the above (48) to (53) wherein thepatient has a fasting blood glucose of at least 110 mg/dL and less than126 mg/dL.

(55) A method according to any one of the above (48) to (53) wherein thepatient has a fasting blood glucose of at least 100 mg/dL and less than110 mg/dL.

(56) A method according to any one of the above (48) to (55) wherein atleast one member selected from the group consisting of icosapentaenoicacid and its pharmaceutically acceptable salts and esters is ethylicosapentate or icosapentaenoic acid (free acid).

(57) A method according to any one of the above (28) to (56) wherein EPAcontent ratio in total fatty acid and its derivatives is at least 96.5%by weight.

(58) A method according to any one of the above (28) to (57) wherein theEPA is orally administered at a dose of 0.9 g/day to 2.7 g/day.

(59) A method according to any one of the above (28) to (58) wherein theEPA is administered at least for 2 years.

(60) A method according to any one of the above (28) to (59) wherein thepharmaceutical composition is used in combination with HMG-CoA RI.

(61) A method according to any one of the above (28) to (60) wherein thecomposition contains the EPA and the HMG-CoA RI.

(62) A method according to any one of the above (28) to (61) wherein thecomposition is used in combination with a diet therapy.

(63) A method according to any one of the above (28) to (62) wherein thecomposition is capable of, in a patient administered with statin(HMG-CoA RI), reducing the incidence rate of the cardiovascular event,and in particular incidence rate of the cardiovascular event that couldnot be prevented by the single administration of the HMG-CoA RI, orserum T-Cho concentration and/or serum TG concentration.

(64) A method for advertising a pharmaceutical composition used in anyone of the methods:

1) a method for reducing new incidence rate of diabetes due toadministration of HMG-CoA RI,

2) a method for suppressing increase of blood glucose due toadministration of the HMG-CoA RI, and

3) a method for improving abnormal glucose tolerance or obesity of apatient administered with HMG-CoA RI having abnormal glucose toleranceor obesity,

which comprises the step of administering a pharmaceutical compositioncontaining at least one member selected from the group consisting oficosapentaenoic acid and its pharmaceutically acceptable salts andesters as its effective component to a patient administered with statin(HMG-CoA RI).

The information on the method as described above of the presentinvention is provided to physicians and test participants. Morespecifically, such information is provided, for example, by thedistribution of brochure or electric medium or by the provision of theinformation through the internet.

Advantageous Effects of Invention

The pharmaceutical composition of the present invention provides a meansfor reducing the new incidence rate of diabetes due to statinadministration in the patients administered with statin (HMG-CoA RI). Ofthe patients administered with statin, the pharmaceutical composition ofthe present invention is particularly effective for those having higherrisk of diabetes incidence. The pharmaceutical composition of thepresent invention also provides a means for suppressing increase ofblood glucose due to statin administration in the patients administeredwith statin (HMG-CoA RI). Of the patients administered with statin, thepharmaceutical composition of the present invention is particularlyeffective for those who are susceptible to undergo blood glucoseincrease. Furthermore, the pharmaceutical composition of the presentinvention has high safety and reduced side effects.

The pharmaceutical composition of the present invention also provides ameans for reducing the new incidence rate of diabetes due to statinadministration and/or suppressing increase of blood glucose due tostatin administration in the patients administered with statin (HMG-CoARI), and in particular, a means for realizing effects such as the effectof preventing the incidence of cardiovascular events which could not beprevented by solely administering the HMG-CoA RI and the effect ofreducing the serum T-Cho concentration and serum TG.

BRIEF DESCRIPTION OF DRAWING

FIG. 1 is a graph showing the effect of the statin and the EPA onglucose uptake by cultivated human rhabdomyosarcoma cell.

DESCRIPTION OF EMBODIMENTS

Next, the present invention is described in detail.

1. Pharmaceutical Composition (1) Effective Components

The pharmaceutical composition of the present invention contains atleast one member selected from the group consisting of icosapentaenoicacid and its pharmaceutically acceptable salts and esters as itseffective component.

Examples of the pharmaceutically acceptable salt include inorganic saltssuch as sodium salt and potassium salt, salts with an organic base suchas benzylamine salt and, diethylamine salt, and salts with a basic aminoacid such as arginine salt and lysine salt.

Examples of the pharmaceutically acceptable ester include alkyl esterssuch as ethyl ester and glycerin ester such as mono-, di-, andtri-glycerides.

The EPA is preferably ethyl icosapentate (hereinafter also referred toas “EPA-E”), icosapentaenoic acid (free acid) or sodium eicosapentate(hereinafter also referred, to as “EPA-Na”), and more preferably, EPA-E.

The EPA is not particularly limited for its purity. However, content ofthe EPA in the all fatty acids in the pharmaceutical composition of thepresent invention is typically at least 25% by weight, preferably atleast 40% by weight, more preferably at least 50% by weight, still morepreferably at least 70% by weight, still more preferably at least 85% byweight, still more preferably at least 96.5% by weight, and the mostpreferred is the embodiment wherein the composition is substantiallyfree from the fatty acid other than the EPA.

When the at least one member selected from the group consisting oficosapentaenoic acid and its pharmaceutically acceptable salts andesters is EPA-E, content of the impurities which are preferable forcardiovascular events such as saturated fatty acid and arachidonic acidwill be reduced, and the desired action and effect will be realizedwithout the problems of excessive nutrition or excessive intake ofvitamin A. Since EPA-E is an ester, it has a higher stability tooxidation compared to fish oils which mainly comprises a triglyceride,and a sufficiently stable composition will be produced by adding acommonly used antioxidant. The antioxidant added may be, for example, atleast one antioxidant selected from butylated hydroxytoluene, butylatedhydroxyanisole, propyl gallate, gallic acid, and pharmaceuticallyacceptable quinone and α-tocopherol, and such agent may be added at aneffective amount.

When the at least one member selected from the group consisting oficosapentaenoic acid and its pharmaceutically acceptable salts andesters is EPA (free acid), content of the impurities which areunpreferable for cardiovascular events such as saturated fatty acid andarachidonic acid will be reduced, and the desired action and effect willbe realized without the problems of excessive nutrition or excessiveintake of vitamin A. In addition, since the EPA is a free acid, cleavageof ester bond by elastase is unnecessary in the absorption in theintestinal tract, and absorption higher than that of EPA-E ortriglyceride form is expected particularly in the case of fastingadministration. The antioxidant added may be, for example, at least oneantioxidant selected from butylated hydroxytoluene, butylatedhydroxyanisole, propyl gallate, gallic acid, and pharmaceuticallyacceptable quinone and α-tocopherol, and such agent may be added at aneffective amount.

Exemplary dosage form of the preparation include oral administration tothe patient in the form of tablet, capsule, microcapsule, granules, finegranules, powder, oral liquid preparation, emulsion, self-emulsifyingpreparation, syrup, and jelly, and the particularly preferred is oraladministration by incorporating the composition in the capsule such assoft capsule or microcapsule. Exemplary EPA-E include a soft capsulecontaining high purity EPA-E (at least 96.5% by weight) (product name,Epadel, manufactured by Mochida Pharmaceutical Co., Ltd.) which areavailable in Japan as therapeutic agents for arteriosclerosis obliteransor hypertriglyceridemia, and a soft capsule containing high purity EPA-E(product name, Vascepa, manufactured by Amarin Pharma Inc.), a softcapsule containing about 46% by weight of EPA-E and about 38% by weightof DHA-E in the total fatty acid (Lovaza manufactured by GlaxoSmithKlineand Omacor manufactured by ProNova Inc.), and a soft capsule containing50 to 60% by weight of EPA (free acid) and 15 to 25% by weight of DHA(free acid) in the total fatty acid (Epanova manufactured by Omthera)which are approved in the U.S. as therapeutic agents for severehypertriglyceridemia.

When the pharmaceutical composition of the present invention is orallyadministered, preferably 0.1 to 10 g/day, more preferably 0.3 to 6g/day, still more preferably 0.6 to 4 g/day, and even more preferably0.9 to 2.7 g/day of EPA-E is administered in 1 to 3 doses, and ifnecessary or if desired, the composition may be administered in 1 toseveral doses. The composition is preferably administered during orafter the meal, and more preferably, immediately (within 30 minutes)after the meal. In the case of self-emulsifying preparation (forexample, see WO 2010/134614) which exhibits high fasting absorption, thepreparation may be administered not during the meal, after the meal, orimmediately after the meal. The pharmaceutical composition of thepresent invention may also be used in combination with the diet therapy(for example, limitation of daily calorie, regular meal, balanced diet,balanced intake of nutritional elements (carbohydrate, protein, fat,mineral, vitamin, dietary fiber, and the like), etc.), and in such acase, daily dose, frequency, and/or timing of the administration can beadjusted as desired. The daily dose and frequency of the EPA (free acid)administration when the pharmaceutical composition of the presentinvention contains the EPA (free acid) may be determined by referring tothe pharmaceutical composition containing EPA-E.

When the dose as described above is orally administered, theadministration is preferably conducted while administering the statin.For example, the administration period is at least 1 year, preferably atleast 2 years, more preferably at least 3 years, and still morepreferably at least 5 years, and the administration is preferablycontinued while there is the risk of the incidence rate of new diabetesand/or blood glucose increase due to the statin administration is stillpresent. If desired, drug withdrawal period of approximately 1 day to 3months, and preferably approximately 1 week to 1 month may be included.

The administration period may be adequately set depending on the type ofthe disease to be treated and the degree of the symptom. For example,when the disease to be treated is dyslipidemia, the administrationperiod is not particularly limited when the administration is conductedto achieve the effects of improving or treating dyslipidemia-relatedbiochemical marker or pathologies or to suppress the progress intometabolic syndrome, cardio-cerebrovascular events, peripheral ulcer,gangrene, and the like. Exemplary conditions include improvement in theconcentration of lipid markers in plasma (total cholesterol (hereinafterreferred to as Cho), TG, TG after the meal, low density lipoprotein Cho,high density lipoprotein Cho, very low density lipoprotein Cho, non-highdensity lipoprotein Cho, intermediate density lipoprotein Cho, very highdensity lipoprotein Cho, free fatty acid, phospholipid, chylomicron,ApoB, lipoprotein (a), and remnant-like protein Cho, small dense lowdensity lipoprotein Cho, etc.), increase in the peripheral skintemperature which can be measured by thermography or the like, increasein the walk distance, improvement of the test value such as serumcreatinine phosphokinase, and improvement of symptoms such as numbness,coldness, pain, pain at rest, itching, cyanosis, redness, chilblain,neck stiffness, anemia, unhealthy complexion, pruritus, and crawling;and the administration may be conducted by monitoring improvement ortherapeutic effects for these conditions. The administration may beconducted by monitoring the improvement or the therapeutic effects usingother biochemical, pathological, or disease parameters. Desirably, theadministration is continued while biochemical marker values such asplasma lipid concentration and abnormal pathology are still observed.

(2) Fatty Acid which May be Incorporated in Addition to the EPA

Examples of other fatty acids (not limited to free fatty acid andincluding pharmaceutically acceptable salts, esters, and otherderivatives, and this also applies to the following description in thisitem) which may be incorporated include ω3 long chain unsaturated fattyacid, which is more preferably at least one member selected from thegroup consisting of docosahexaenoic acid, docosapentaenoic acid, andpharmaceutically acceptable salts and esters thereof (hereinafter alsosimply referred to as “DHA”, and unless otherwise noted, this alsoapplies to the following), and more preferably DHA, and still morepreferably ethyl docosahexaenoate (hereinafter also referred to as“DHA-E”).

When the pharmaceutical composition of the present invention containsEPA-E and DHA-E, the proportion of the total content of the EPA-E andthe DHA-E in the total fatty acid content of the pharmaceuticalcomposition of the present invention is not particularly limited. Theproportion, however, is preferably at least 40% by weight, morepreferably at least 60% by weight, still more preferably at least 80% byweight, and still more preferably at least 90% by weight, and the mostpreferred is the embodiment wherein the fatty acid other than the ω3long chain unsaturated fatty acid is substantially absent. In otherwords, purity of the ω3 long chain unsaturated fatty acid in all fattyacids is preferably high, and more preferably, purity of the EPA and theDHA which are ω3 long chain unsaturated fatty acids is high, and stillmore preferably, purity of the EPA is high. For example, when thepharmaceutical composition of the present invention contains the EPA-Eand the DHA-E, the ratio of the content of the EPA-E to the DHA-E(EPA-E/DHA-E) in all fatty acids of the pharmaceutical composition ofthe present invention is not particularly limited, and the ratio ispreferably at least 0.8, more preferably at least 1.0, and morepreferably at least 1.2. When the pharmaceutical composition of thepresent invention contains the EPA (free acid) and the DHA (free acid),total proportion of the EPA (free acid) and the DHA (free acid) in allfatty acids in the pharmaceutical composition of the present inventionand the ratio of the EPA (free acid) to the DHA (free acid) (EPA/DHA) inall fatty acids in the pharmaceutical composition of the presentinvention corresponds to those of the pharmaceutical compositioncontaining the EPA-E and the DHA-E.

When the pharmaceutical composition of the present invention containsEPA-E and the DHA-E, the daily dose of the EPA-E and the DHA-E which isnot particularly limited is preferably 0.3 to 10 g/day, more preferably0.5 to 6 g/day, and still more preferably 1 to 4 g/day as the total ofthe EPA-E and DHA-E, and if necessary or if desired, the composition maybe administered in 1 to several doses. The composition is preferablyadministered during or after the meal, and more preferably, immediately(within 30 minutes) after the meal. In the case of self-emulsifyingpreparation (for example, see WO 2010/134614) which exhibits highfasting absorption, the preparation may be administered not during themeal, after the meal, or immediately after the meal. The pharmaceuticalcomposition of the present invention may also be used in combinationwith the diet therapy, and in such a case, daily dose, frequency, and/ortiming of the administration can be adjusted as desired. The daily doseand frequency of the EPA (free acid) and and DHA (free acid)administration when the pharmaceutical composition of the presentinvention contains the EPA (free acid) and DHA (free acid) may bedetermined in consideration of the corresponding case of thepharmaceutical composition containing EPA-E and DHA-E as describedabove.

When the dose as described above is administered, the administrationperiod is preferably during the administration of the statin. Forexample, the administration period is at least 1 year, preferably atleast 2 years, more preferably at least 3 years, and still morepreferably at least 5 years, and the administration is preferablycontinued while there is the risk of the incidence rate of new diabetesand/or blood glucose increase due to the statin administration is stillpresent. If desired, drug withdrawal period of approximately 1 day to 3months, and preferably approximately 1 week to 1 month may be included.

The administration period may be adequately set depending on the type ofthe disease to be treated and the degree of the symptom. For example,when the disease to be treated is dyslipidemia, the administrationperiod is not particularly limited when the administration is conductedto achieve the effects of improving or treating dyslipidemia-relatedbiochemical marker or pathologies or to suppress the progress intometabolic syndrome, cardio-cerebrovascular events, peripheral ulcer,gangrene, and the like. Exemplary conditions include improvement in theconcentration of lipid markers in plasma (total cholesterol (hereinafterreferred to as Cho), TG, TG after the meal, low density lipoprotein Cho,high density lipoprotein Cho, very low density lipoprotein Cho, non-highdensity lipoprotein Cho, intermediate density lipoprotein Cho, very highdensity lipoprotein Cho, free fatty acid, phospholipid, chylomicron,ApoB, lipoprotein (a), and remnant-like protein Cho, small dense lowdensity lipoprotein Cho, etc.), increase in the peripheral skintemperature which can be measured by thermography or the like, increasein the walk distance, improvement of the test value such as serumcreatinine phosphokinase, and improvement of symptoms such as numbness,coldness, pain, pain at rest, itching, cyanosis, redness, chilblain,neck stiffness, anemia, unhealthy complexion, pruritus, and crawling;and the administration may be conducted by monitoring improvement ortherapeutic effects for these conditions. The administration may beconducted by monitoring the improvement or the therapeutic effects usingother biochemical, pathological, or disease parameters. Desirably, theadministration is continued while biochemical marker values such asplasma lipid concentration and abnormal pathology are still observed.

Preferably, content of the long chain unsaturated fatty acids other thanthe EPA and the DHA is minimized as far as possible, and in particular,content of the ω6 long chain unsaturated fatty acids, and in particular,arachidonic acid should be minimized as far as possible, and the contentis preferably less than 2% by weight, more preferably less than 1% byweight, still more preferably less than 0.5% by weight, and the mostpreferable is the embodiment wherein the ω6 long chain unsaturated fattyacid is substantially absent.

(3) Use in Combination with Statin

The pharmaceutical composition of the present invention is used incombination with the statin.

The “use in combination with the statin” includes both a simultaneousadministration of the composition containing the EPA as its effectivecomponent with the statin and separate administration of suchcomposition with the statin.

In the case of simultaneous administration, the pharmaceuticalcomposition of the present invention and the statin may be formulated asa combined drug, a kit comprising the combination of these two drugs, ortwo separate drugs.

In the case of separate administration, the pharmaceutical compositionof the present invention and the statin may be used at an adequate doseand ratio.

In addition, in the case of separate administration, the EPA may beadministered either before or after the HMG-CoA RI. When these drugs areadministered at different timings, the drugs may be administered, forexample, by first administering one of the drugs and then administeringthe other drug at the timing when the effects of the first drug startsto be developed or during the full development of such effect for theaction of the second drug. In other cases, one drug may be prepared inthe form of a controlled-release drug and administered once a day, andthe other drug may be administered two or more times, for example, twiceor three times a day, or once a day as in the case of the first drug.The administration of both drugs once a day, or simultaneousadministration both drugs once a day, or use of a preparation containingboth drugs is preferable due to the reduced participant's burden oftaking the drugs, and such administration is expected to result in theimproved compliance and improved preventive/ameliorating or treatingeffects as well as improved effect of reducing the side effects.Alternatively, both drugs may be administered and the administration ofone of the drugs may be stopped when the effects of the first drugstarts to be developed or during the full development of such effect. Instopping the drug administration, the drug dose may be incrementallyreduced. Furthermore, one of the drugs may be administered during drugwithdrawal period of the other drug.

The “use in combination” is not necessarily limited to the cases ofsimultaneous presence in body, for example, in blood of theparticipants. The “use in combination” as used in the present inventionhowever refers to the embodiment of the drug use wherein one of thedrugs is administered while the action or the effect of the other drugis still expressed in the body of the patient.

The action mechanism how the new incidence rate of the diabetes due tostatin is reduced or the increase of the blood glucose due to statin issuppressed by the pharmaceutical composition of the present invention inthe patients administered with the statin not fully elucidated. SinceEPA suppresses the decrease of the glucose take up by skeletal musclecell by the statin, there is a possibility that EPA is suppressing theincrease of the blood glucose due to statin. Suppressing of the bloodglucose increase should result in the decrease of the risk of thediabetes incidence.

Furthermore, the pharmaceutical composition of the present invention isknown to have the action of preventing the incidence of cardiovascularevents, and in particular, the cardiovascular events which cannot beprevented by the single administration of the HMG-CoA RI as well as theaction of reducing the serum T-Cho concentration and serum TG in thehyperlipidemia patients administered with the statin (HMG-CoA RI).Accordingly, increase of the new diabetes incidence rate and/or theblood glucose due to the statin administration will be suppressed, theincidence of cardiovascular events, and in particular, thecardiovascular events which cannot be prevented by the singleadministration of the HMG-CoA RI will be prevented, and the serum T-Choconcentration and serum TG will be reduced in the patients administeredwith statin (HMG-CoA RI).

2. Diabetes (1) Diagnostic Criteria of Diabetes

In the present invention, the patient who was at least once observed tohave the fasting blood glucose of 126 mg/dL or higher is recognized as apatient suffering from diabetes.

It is to be noted that, in the clinical diagnostic criteria of thediabetes, a patient is diagnosed as diabetes when a) both blood glucoseand HbA1c are diabetic in the initial examination (preferably measuredon the same day, and this applies to the following), b) only bloodglucose is diabetic in the initial examination, and typical diabeticsymptoms or accurate diabetic retinopathy is found in the initial test,c) only blood glucose is diabetic in the initial examination, and bothtypical diabetic symptoms and accurate diabetic retinopathy are absent,and the blood glucose and/or the HbA1c is diabetic in the reexamination,and d) HbA1c is diabetic in the initial examination, and both bloodglucose and HbA1c are diabetic, or only the blood glucose is diabetic inthe reexamination.

(2) New Incidence and New Incidence Rate of the Diabetes

In the present invention, the term “new incidence of the diabetes” isused when a fasting blood glucose of 126 mg/dL or higher is measured atleast once in the patient who has never been diagnosed as diabetes, andpreferably in the patient who has no experience of the measurement of126 mg/dL or higher.

The “new incidence rate of the diabetes” is percentage of the number ofpatient who has experienced the new incidence of the diabetes in thenumber of all patients administered with HMG-CoA RI.

3. Patients Who are Subject to the Administration of the PharmaceuticalComposition of the Present Invention (1) The Pharmaceutical Compositionfor Reducing the New Diabetes Incidence

The patients subject to the administration of the pharmaceuticalcomposition of the present invention for reducing the new incidence ofthe diabetes due to the administration of statin are not particularlylimited as long as the patient is administered with the statin (HMG-CoARI) and the patient has no experience of the incidence of the diabetes.Such patients are preferably those who have not experienced theincidence of the diabetes but who have higher risk of incidence sincethe effect of the pharmaceutical composition of the present invention toreduce the new diabetes incidence due to statin is more significant inpatients who have higher risk of diabetes incidence.

Exemplary patients who have higher risk of diabetes incidence includethose who are suffering from hyper-LDL-cholesterolemia or borderlinehyper-LDL-cholesterolemia simultaneously with preferably lowHDL-cholesterolemia, and more preferably low HDL-cholesterolemia andhypertriglyceridemia. It is to be noted that the diagnostic criteria ofthe hyper-LDL-cholesterolemia, the borderline hyper-LDL-cholesterolemia,the low HDL-cholesterolemia, and the hypertriglyceridemia arerespectively serum LDL-C equal to or greater than 140 mg/dL, serum LDL-Cof 120 to 139 mg/dL, serum HDL-C of less than 40 mg/dL, and serum TGequal to or greater than 150 mg/dL. These diagnostic criteria, however,are preferably renewed when the diagnostic criteria is revised.

Another group of patients who have higher risk of diabetes incidence is,for example, patients whose fasting blood glucose is in the borderlinerange or at a normal high value. The “borderline range” is the fastingblood glucose of at least 110 mg/dL and less than 126 mg/dL, and the“normal high value” is the fasting blood glucose of at least 100 mg/dLand less than 110 mg/dL. However, these thresholds are preferablyrenewed when the thresholds are revised.

Another group of patients who have higher risk of diabetes incidence is,for example, patients who are suffering from impaired glucose toleranceor obesity. The patients who are suffering from impaired glucosetolerance or obesity are conceived to be those having higher risk ofdiabetes incidence compared to the patients who are not suffering fromthe impaired glucose tolerance or obesity.

In the present invention, “impaired glucose tolerance” means that thevalue at 2 hours in OGTT (75 g oral glucose tolerance test) is neithernormal type nor diabetes type. The 2 hour OGTT value is normal type whenthe 2 hour OGTT value is less than 140 mg/dL, and the 2 hour OGTT valueis diabetes type when the 2 hour OGTT value is 200 mg/dL or higher.

In the present invention, “obesity” means the state of excessive adiposetissue accumulation. While the criteria may vary by the country, theterm “obesity” is determined by the diagnostic criteria of Japan Societyfor the Study of Obesity, namely, the body-mass index (hereinafter, alsoreferred to as “BMI”) of at least 25.

(2) The Pharmaceutical Composition for Suppressing the Increase of theBlood Glucose

The patients subject to the administration of the pharmaceuticalcomposition of the present invention for suppressing the increase of theblood glucose due to the administration of statin are not particularlylimited as long as the patient is administered with statin (HMG-CoA RI).Such patients are preferably those who have not experienced theincidence of the diabetes, and more preferably, those who have notexperienced the incidence of the diabetes but who are susceptible toexperience increase in the blood glucose since the effect of thepharmaceutical composition of the present invention to suppress theincrease of the blood glucose due to statin is more significant inpatients who are susceptible to experience increase in the bloodglucose.

Exemplary patients who are susceptible to experience increase of theblood glucose include those who are suffering fromhyper-LDL-cholesterolemia or borderline hyper-LDL-cholesterolemiasimultaneously with preferably low HDL-cholesterolemia, more preferablylow HDL-cholesterolemia and hypertriglyceridemia. It is to be noted thatthe diagnostic criteria of the hyper-LDL-cholesterolemia, the borderlinehyper-LDL-cholesterolemia, the low HDL-cholesterolemia, and thehypertriglyceridemia are respectively serum LDL-C equal to or greaterthan 140 mg/dL, serum LDL-C of 120 to 139 mg/dL, serum HDL-C of lessthan 40 mg/dL, and serum TG equal to or greater than 150 mg/dL. Thesediagnostic criteria, however, are preferably renewed when the diagnosticcriteria is revised.

Another group of patients who are susceptible to experience increase ofthe blood glucose is, for example, patients whose fasting blood glucoseis in the borderline range or at a normal high value. The “borderlinerange” is the fasting blood glucose of at least 110 mg/dL and less than126 mg/dL, and the “normal high value” is the fasting blood glucose ofat least 100 mg/dL and less than 110 mg/dL. These thresholds, however,are preferably renewed when the thresholds are revised.

Another group of patients who are susceptible to experience increase ofthe blood glucose is, for example, patients who are suffering fromimpaired glucose tolerance or obesity. The patients who are sufferingfrom impaired glucose tolerance or obesity are conceived to be thosehaving higher risk of diabetes incidence compared to the patients whoare not suffering from the impaired glucose tolerance or obesity.

In the present invention, “impaired glucose tolerance” means that thevalue at 2 hours in OGTT (75 g oral glucose tolerance test) is neithernormal type nor diabetes type. The 2 hour OGTT value is normal type whenthe 2 hour OGTT value is less than 140 mg/dL, and the 2 hour OGTT valueis diabetes type when the 2 hour OGTT value is 200 mg/dL or higher.

In the present invention, “obesity” means the state of excessive adiposetissue accumulation. While the criteria may vary by the country, theterm “obesity” is determined by the diagnostic criteria of Japan Societyfor the Study of Obesity, namely, the BMI of at least 25.

(3) Statin

The statin (HMG-CoA RI) is not particularly limited as long as it is adrug which inhibits HMG-CoA reductase, and examples includeatorvastatin, simvastatin, cerivastatin, fluvastatin, pravastatin,rosuvastatin, pitavastatin, lovastatin, and their pharmaceuticallyacceptable salts. Exemplary commercially available products includeatorvastatin calcium (product name, Lipitor, Astellas Pharma/PfizerInc.), simvastatin (product name, Lipovas, MSD), cerivastatin sodium,fluvastatin sodium (product name, Lochol, Novartis Pharma), pravastatinsodium (product name, Mevalotin, Daiichi Sankyo), rosuvastatin calcium(product name, Crestor, Shionogi), pitavastatin calcium (product name,Livalo, Kowa), and lovastatin (product name, Mevacor, MSD). The term“statin” and “HMG-CoA RI” as used herein in relation to thepharmaceutical composition of the present invention include all of thoseas mentioned above.

The type of statin is not particularly limited. However, combinationwith a statin which is highly effective for reducing the cardiovascularrisk is preferable since the statin which is highly effective forreducing the cardiovascular risk is also likely to have a high risk ofdiabetes incidence. For example, the preferred are atorvastatin,rosuvastatin, and simvastatin, and the more preferred are atorvastatinand rosuvastatin. The most preferred is atorvastatin.

Statin is preferably used by the prescribed method and at the prescribeddose, and the dose may be adjusted depending on the type, dosage form,administration route and daily frequency of the statin, degree of thesymptom, body weight, sex, age, and the like. In the case of oraladministration, 0.05 to 200 mg/day, and preferably 0.1 to 100 mg/day ofstatin may be administered at once or in two divided doses, and ifdesired, total dose may be administered in several divided doses. Thedose may be reduced depending on the amount of the EPA-E administered.

It is to be noted that daily dose is preferably 5 to 60 mg, and morepreferably 10 to 20 mg in the case of sodium pravastatin; preferably 2.5to 60 mg, and more preferably 5 to 20 mg in the case of simvastatin;preferably 10 to 180 mg, and more preferably 20 to 60 mg in the case offluvastatin sodium; preferably 5 to 120 mg, and more preferably 10 to 40mg in the case of atorvastatin calcium hydrate; preferably 0.5 to 12 mg,and more preferably 1 to 4 mg in the case of pitavastatin calcium;preferably 1.25 to 60 mg, and more preferably 2.5 to 20 mg in the caseof rosuvastatin calcium; preferably 5 to 160 mg, and more preferably 10to 80 mg in the case of lovastatin; and preferably 0.075 to 0.9 mg, andmore preferably 0.15 to 0.3 mg in the case of cerivastatin sodium;although the dose is not limited to those as described above.

The pharmaceutical composition and the method of the present inventionmay be used by incorporating other drug in addition to the EPA. Theadditional drug used in the present invention is not particularlylimited as long as it does not adversely affect the merit of the presentinvention, and exemplary such drugs include hypoglycemic/antidiabetic,lipid-lowering drug, antihypertensive, antioxidant, andanti-inflammatory agent.

Exemplary hypoglycemic/antidiabetic drugs include α-glucosidaseinhibitors such as acarbose, voglibose, and miglitol, sulfonyl ureahypoglycemics such as gliclazide, glibenclamide, glimepiride, andtolbutamide, rapid-acting insulin secretagogues such as nateglinide,repaglinide, and mitiglinide, biguanide hypoglycemics such as metforminhydrochloride, and buformin hydrochloride, dipeptidyl phosphatase 4inhibitors such as sitagliptin, vildagliptin, alogliptin, andsaxagliptin, thiazolidine drugs such as pioglitazone hydrochloride androsiglitazone maleate, glucagon-like peptide 1 derivatives such asexenatide and liraglutide, insulin, and insulin derivatives.

Exemplary lipid-lowering drugs include fibrate drugs such as simfibrate,clofibrate, clinofibrate, bezafibrate, and fenofibrate, and lipaseinhibitors such as orlistat and cetilistat, resins such ascholestyramine and colestimide, and ezetimibe.

Exemplary antihypertensives include angiotensin II receptor blockerssuch as irbesartan, olmesartan medoxomil, candesartan cilexetil,telmisartan, valsartan, losartan potassium, angiotensin-convertingenzyme inhibitors such as alacepril, imidapril hydrochloride, enalaprilmaleate, captopril, quinapril hydrochloride, cilazapril hydrate,temocapril hydrochloride, delapril hydrochloride, trandolapril,benazepril hydrochloride, perindopril, and lisinopril hydrate, calciumantagonists such as azelnidipine, amlodipine besylate, aranidipine,efonidipine hydrochloride, cilnidipine, nicardipine hydrochloride,nifedipine, nimodipine, nitrendipine, nilvadipine, barnidipinehydrochloride, felodipine, benidipine, and manidipine, a blockers suchas tolazoline and phentolamine, β blockers such as atenolol, metoprolol,acebutolol, propranolol, pindolol, carvedilol, and labetalolhydrochloride, a stimulants such as clonidine and methyldopa, anddiuretics such as eplerenone, hydrochlorothiazide, and furosemide.

Exemplary antioxidants include vitamins such as ascorbic acid (vitaminC), tocopherol (vitamin E), and tocopherol nicotinic acid ester,N-acetyl cysteine, and probucol.

Exemplary anti-inflammatory agents include cytokine production inhibitorsuch as pentoxifylline, leukotriene receptor antagonist, leukotrienebiosynthesis inhibitor, NSAIDs, COX-2 selective inhibitor, M2/M3antagonist, steroids such as corticosteroid and prednisolonefarnesylate, Hi (histamine) receptor antagonist, aminosalicylic acidssuch as salazosulfapyridine and mesalazine. Exemplary immunosuppressantsinclude azathioprine, 6-mercaptoprine, and tacrolimus. Exemplaryantiviral agents for hepatitis C virus (HCV) include interferon,protease inhibitor, helicase inhibitor, and polymerase inhibitor.

EXAMPLES

[Suppression of the New Incidence of Diabetes in Patients Administeredwith HMG-CoA RI by EPA Administration]

The test data obtained in JELIS (Japan EPA Lipid Intervention Study)which is a large-scale randomized comparative test conducted since 1996was examined for examining the effect of suppressing the incidence(primary and secondary prevention) of the coronary artery event inducedby long-term administration of high purity EPA preparation in Japanesehyperlipidemia patients

1. Summary of the JELIS Test (1) Subjects

Hyperlipidemia patients with serum total cholesterol of at least 250mg/dL (men aged 40 to 75 years and postmenopausal women aged up to 75years with serum total cholesterol of at least 250 mg/dL) were eligiblefor the study, and a total of 18,645 cases (14,981 primary preventioncases, 3,664 secondary prevention cases) were studied.

(2) Test Method

The hyperlipidemia patients were divided into 2 groups, namely, thecontrol group (9,319 cases, the group with no EPA administration) andEPA group (9,326 cases), and the EPA group was administered with 1800mg/day of high purity EPA preparation. Simultaneously, both groups wereadministered with statin (10 to 20 mg/day of pravastatin sodium, 5 to 10mg/day of simvastatin, or 10 to 20 mg/day of atorvastatin calcium interms of atorvastatin). The groups were followed for about 5 years, andevaluation was conducted. It is to be noted that the hyperlipidemiapatients in the JELIS test were those having the serum total cholesterol(TC) concentration of at least 250 mg/dL including the patients whoseserum TC concentration would be at least 250 mg/dL if the lipid was notcontrolled.

2. Analysis of New Incidence of Diabetes (1) Subject

15,605 cases without definite diagnosis of the diabetes (EPA group,7,810 cases; control group 7,795 cases) were extracted from 18,645 casesregistered in JELIS, and these cases were designated “group 1”. As aconsequence, 3,040 cases with definite diagnosis of the diabetes (notlimited to Type 2 diabetes and including all types) were excluded fromthe entire registered cases.

Next, 15,311 cases including the cases with the fasting blood glucose ofless than 126 mg/dL and the cases wherein the fasting blood glucose hadnot been measured (EPA group, 7,650 cases; control group, 7,661 cases)were extracted from group 1, and this group was designated “group 2”. Asa consequence, 294 cases with the blood glucose at the time ofregistration of at least 126 mg/dL were excluded from the group 1.

Next, 7,875 cases including the cases wherein the fasting blood glucosehad been measured at least once in the observation period (EPA group,3,976 cases; control group, 3,899 cases) were extracted from group 2,and this group was designated “group 3”. As a consequence, 7,436 caseswherein the fasting blood glucose was not at all measured in theobservation period were excluded from the group 2.

Furthermore, the cases wherein the serum HDL-C concentration was lessthan 40 mg/dL with no limitation in the serum TG were extracted fromeach of the group 1, group 2, and group 3, and this group was designatedsubgroup “HDL-C<40, no limitation in TG”, and the cases wherein theserum HDL-C concentration was less than 40 mg/dL and the serum TG was atleast 150 mg/dL were extracted from each of the group 1, group 2, andgroup 3, and this group was designated subgroup “HDL-C<40 and TG≥150”

The number of patients who experienced new incidence of the diabetes(DM: Diabetes Mellitus) during the JELIS test (number of DM incidence),proportion of such patients (DM incidence rate, %), and the suppressionrate of DM incidence by EPA administration (%) are shown in Table 1.

TABLE 1 Number of patients experiencing new incidence and new incidencerate of Diabetes Mellitus HDL-C < 40 Serum lipid HDL-C No limitation onNo limitation HDL-C < 40 [mg/dL] TG HDL-C and TG on TG TG ≥ 150 Group 1EPA Total number 7810 620 501 group DM Incidence 259 24 22 numberIncidence 3.3% 3.9% 4.4% rate Control Total number 7795 642 523 group DMIncidence 242 39 34 number Incidence 3.1% 6.1% 6.5% rate Suppressionrate of DM incidence −6.8% 36.3% 32.5% Group 2 EPA Total number 7650 608486 group DM Incidence 219 22 20 number Incidence 2.9% 3.6% 4.1% rateControl Total number 7661 637 514 group DM Incidence 203 35 32 numberIncidence 2.6% 5.5% 6.2% rate Suppression rate of DM incidence −8.0%34.1% 33.9% Group 3 EPA Total number 3976 295 239 group DM Incidence 21321 19 number Incidence 5.4% 7.1% 7.9% rate Control Total number 3899 325273 group DM Incidence 201 35 32 number Incidence 5.2% 10.8% 11.7% rateSuppression rate of DM incidence −3.9% 33.9% 32.2%

Furthermore, the cases wherein the fasting blood glucose was at least110 mg/dL and less than 126 mg/dL were extracted from the subgroup“HDL-C<40, no limitation in TG” and the subgroup “HDL-C<40 and TG≥150”of the group 3, and the number of DM incidence, the DM incidence rate,and the suppression rate of DM incidence are shown in Table 2.

TABLE 2 Number of patients experiencing new incidence and new incidencerate of Diabetes Mellitus 110 ≤ FPG < 126 Fasting blood glucose (FPG)[mg/dL] HDL-C < 40 110 ≤ FPG < 126 Serum lipid HDL-C No limitation HDL-C< 40 [mg/dL] TG on TG TG ≥ 150 Group 3 EPA group Total number 25 19 DMIncidence 4 3 number Incidence 16.0% 15.8% rate Control Total number 1917 group DM Incidence 5 5 number Incidence 26.3% 29.4% rate Suppressionrate of DM incidence 39.2% 46.3%

It is to be noted that the incidence of the DM in Tables 1 and 2 meansthe new incidence of the DM, namely, the measurement of the fastingblood glucose of 126 mg/dL or higher in the patient who has never beendiagnosed as diabetes, and preferably in the patient who has noexperience of the measurement of 126 mg/dL or higher.

The overall results shown in Tables 1 and 2 were generally summarized,and the following suppressive effects by EPA may be expected as theeffect of suppressing the new incidence of diabetes due to statinadministration:

(1) suppression of about 34 to 36% in the patients with the HDL-C ofless than 40 mg/dL,

(2) suppression of about 32 to 35% in the patients with the HDL-C ofless than 40 mg/dL and the TG of 150 mg/dL or higher,

(3) suppression of about 39% in the patients with the fasting bloodglucose of at least 110 mg/dL and less than 126 mg/dL and the HDL-C ofless than 40 mg/dL, and

(4) suppression of about 46% in the patients with the fasting bloodglucose of at least 110 mg/dL and less than 126 mg/dL, the HDL-C of lessthan 40 mg/dL, and the TG of at least 150 mg/dL.

[Suppression by EPA of the Decrease of Glucose Uptake by Skeletal MuscleCells Induced by Statin] 1. Materials and Methods

(1) Human fetal rhabdomyosarcoma cell line (RD cell, ATCC) wasinoculated in 24 well plate and cultured in a growth medium (10% fetalbovine serum (FCS), Dulbecco's modified Eagle medium (DMEM), lowglucose, 1% nonessential amino acid) to confluency.(2) The cells were then cultivated in differentiation medium (2% horseserum (HS), Dulbecco's modified Eagle medium (DMEM), low glucose, 1%nonessential amino acid) for 3 to 5 days for differentiation into musclecell.(3) The cells were then cultivated in the differentiation mediumsupplemented with 0.5% of bovine serum albumin (BSA) (hereinafterreferred to as “differentiation medium (0.5% BSA)”), the differentiationmedium (0.5% BSA) supplemented with 30 μM of statin (simvastatin), thedifferentiation medium (0.5% BSA) supplemented with 50 μM of EPA (sodiumeicosapentate), or the differentiation medium (0.5% BSA) supplementedwith 50 μM of EPA (sodium eicosapentate) and 30 μM of statin(simvastatin) for 1 hr, 6 hr, 24 hr, or 48 hr.

The differentiation medium (0.5% BSA) supplemented with neither statinnor EPA was used for the control group (Cont.), the one supplementedonly with the 30 μM of statin (simvastatin) was used as “statin group(Statin)”, the one supplemented only with the 50 μM of EPA (sodiumeicosapentate) was used as “EPA group (EPA)”, and the one supplementedwith both the 30 μM of statin (simvastatin) and the 50 μM of EPA wasused as “statin+EPA group (Statin+EPA)”.

(3) After the incubation, the medium was removed by aspiration, and thecells were incubated in an uptake buffer (140 mM NaCl, 5 mM KCl, 2.5 mMMgSO₄, 20 mM HEPES, 1 mM CaCl₂, pH=7.4) supplemented with 10 μM of2-3H-deoxyglucose at 37° C. for 12 minutes.(4) After the incubation, the cells were washed 4 times with cold stopsolution (PBS(−)supplemented with 10 mM glucose).

The PBS(−) contained 0.2 g of NaH₂PO₄.2H₂O, 3.225 g of Na₂HPO₄.12H₂O,and 8 g of NaCl in 1 L, and the pH was at 7.2 to 7.4.

(5) After the washing, 500 μL/well of aqueous solution of 0.4N sodiumhydroxide was added, and the cells were lyzed by heating to 56° for 20minutes.(6) 300 μL of the well content (cell lysate) was mixed with 4 mL ofAtomlight (manufactured by PerkinElmer), and ³H count was measured witha liquid scintillation counter. The well content (cell lysate) was alsomeasured for its protein concentration to calculate the ³H count per 1μg of the protein.

2. Results and Analysis (1) Uptake of Radioactivity

Table 3 shows radioactivity per 1 μg of protein (unit: dpm/μg protein)measured by using the liquid scintillation counter. FIG. 1 is the graphshowing the uptake of radioactivity (y axis) in relation to theincubation time (x axis) for each group.

TABLE 3 Uptake of radioactivity Incubation time [hr] 1 6 24 48 Cont. 521519 485 627 EPA 503 513 537 673 Statin 563 489 343 170 Statin + EPA 504491 424 399 Unit: dpm/μg protein

(2) Effects of Statin

In the statin group (Statin), the uptake of the radioactivity is littledifferent from that of the control group (Cont.) within 6 hr ofcultivation. However, the radioactivity uptake drastically decreased at24 hr and 48 hr of cultivation, and the rate of decrease at 48 hr ofincubation was about 73%. In summary, the glucose uptake ability by theskeletal muscle cell decreases in the presence of statin.

This result indicates that the glucose uptake ability by the skeletalmuscle cell in the patients administered with statin is impaired andthey are in the condition of tendency of the blood glucose increase.

(3) Effects of EPA

In the EPA group (EPA), the uptake of the radioactivity tends to keep upwith that of the control group (Cont.). However, the radioactivityuptake somewhat improved at 24 hr and 48 hr of incubation, and the rateof improvement at 48 hr of incubation was about 7%. In summary, theglucose uptake ability by the skeletal muscle cell somewhat increases inthe presence of EPA.

This result indicates the possibility of somewhat improved glucoseuptake ability of the skeletal muscle cell in the patients administeredwith EPA.

(4) Effects of the Copresence of Statin and EPA

In the statin+EPA group (Statin+EPA), the uptake of the radioactivity isnot much different from that of the control group (Cont.) within 6 hr ofincubation while the radioactivity uptake considerably decreased at 24hr and 48 hr of incubation and the rate of decrease at 48 hr ofincubation was about 36%. This decrease, however, was smaller comparedto the statin group (Statin), and the suppression rate in the presenceof the EPA was about 50% of the decrease by the statin. In summary,decrease of the glucose uptake ability by the skeletal muscle cell issuppressed in the presence of the EPA.

It can be elucidated from the results that administration of the EPA toa patient administered with the statin leads to the suppression of thedecrease of the glucose uptake ability of the skeletal muscle cell dueto the statin, and this in turn suppresses the risk of blood glucoseincrease. In other words, the results indicate the possibility that theEPA suppresses the increase of the blood glucose due to the statinadministration.

1. A method of reducing an incidence of diabetes in a subject in needthereof, the method comprising administering to the subject a statin anda pharmaceutical composition containing at least one member selectedfrom the group consisting of eicosapentaenoic acid and itspharmaceutically acceptable salts and esters, wherein the subject has aserum triglyceride concentration of at least 150 mg/dL.
 2. The method ofclaim 1, further comprising administering rosiglitazone to the subject.3. The method of claim 1, wherein the subject has hypertriglyceridemia.4. The method of claim 1, wherein the subject has a high risk of adiabetes incidence.
 5. The method of claim 1, wherein the subject has aserum total cholesterol level at least about 250 mg/dL.
 6. The method ofclaim 1, wherein the subject has a serum total cholesterol level about250 mg/dL.
 7. The method of claim 1, wherein the subject has an LDL-Clevel of about 120 mg/dL.
 8. The method of claim 1, wherein the subjecthas a fasting blood glucose of less than 126 mg/dL.
 9. The method ofclaim 1, wherein the subject has a fasting blood glucose of at least 110mg/dL and less than 126 mg/dL.
 10. The method of claim 1, wherein thesubject has impaired glucose tolerance or obesity.
 11. The method ofclaim 1, wherein at least one member selected from the group consistingof eicosapentaenoic acid and its pharmaceutically acceptable salts andesters is ethyl eicosapentate or eicosapentaenoic acid.
 12. The methodof claim 1, wherein the pharmaceutical composition comprises at leastabout 96.5%, by weight, at least one member selected from the groupconsisting of eicosapentaenoic acid and its pharmaceutically acceptablesalts and esters of a total weight of fatty acids in the pharmaceuticalcomposition.
 13. The method of claim 1, wherein the pharmaceuticalcomposition is administered to the subject for at least about 2 years.